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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> 3 (For Non-Transferable, Revocable, and Suspendable) <br /> r ENVIRONMENTAL HEALTH PERMIT SEPTAGE �) <br /> LIQUID WASTE <br /> Application is h reby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,F Business Name (DBA) Address d <br /> aOwner �. Address -2 ' <br /> J Firm Partners, Addresses and T le ho a Numbers <br /> a Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print)- <br /> Title Cp C Date <br /> Please check Applicable Category(1-7) and Fill In the Required Information w:.^ ;raj C;-:"fjC Sf r'ei SERVICE <br /> ] <br /> 1, ❑"PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> 26' Sq, Oro Sl.`'; i,:;, Ccaif. 95205 f <br /> For July 1, June 30, 19 Disposal Sites 4: 67172 p <br /> Description{Make/Yr., Color} <br /> Serial No. Y CAL. License No. m -` '" CAL, License Renewal No. <br /> Capacity Gal., Weights & Measures No. T t <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD i <br /> II <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored ' <br /> .No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name _ R.S. or R.G.E. No. <br /> Test Location T st to/Time <br /> 4. El SANITATION PERMIT l 1 <br /> Job Address/ cation C:J� drl <br /> Owner Address Z- ? <br /> i <br /> SEPTIC TANK ❑ GESSPOOL" LEACHING FIELD ❑ SEEPAGE PIT 1:1 PACKAGE PLANT <br /> XPERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER i <br /> 5. ❑ CHEMICAL TOILETS Fdr July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name I Where Certified <br /> Plant Location <br /> .[Plant Capacity __._ .— No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19' <br /> "SIZE: ❑ Less Than 1,000 Sq. Ft., i. ❑ More Than 1,000 Sq. Ft' 4 <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. A <br /> i� <br /> hereby certify that I have:prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, ands gulations of the San Joaquin L at Health District: <br /> APPLICANT'S SIGNATURE X y <br /> I 717 <br /> i <br /> ii FOR DEPARTMENT E NL <br /> k <br /> Fee IS Dile: ❑ ANNUALLY ❑ PER UNIT PER SITE 0 EACH a 1 $Received 8y January 31 ❑ July 1 &Received-By July 31 <br /> i' BILLING R ANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DA DATE REMITTED J� I AMOUNT <br /> FEE <br /> LESS <br /> PRORATION j <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER s <br /> s; b 9 a <br /> Received by Date -79- 9-7S -7 <br /> Receipt No. Permit No Issuance Date Mailed elive d <br /> APPLICANT—RETURN ALL COPIES TOi ENVIRONMENTAL HEALTH PERMIT/SERVICES 16(11 E.HAZELTON AVE„P.O.Box 2009 C N,CA95201 "" <br />